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Difficulty: MediumPharmacological Therapies

An older adult client in an inpatient rehabilitation facility is prescribed oral extended-release morphine for chronic pain management. When the practical nurse approaches the client to administer the morning dose, the client is difficult to awaken and has a respiratory rate of 9 breaths per minute. Which action should the nurse take first?

  1. Withhold the medication and urgently notify the supervising registered nurse.Answer
  2. B
    Administer the scheduled analgesic to ensure the client's pain remains consistently controlled.
  3. C
    Document the difficult arousal as an expected age-related change and continue routine monitoring.
  4. D
    Scan the medication barcode but bypass checking the client's identification band to avoid disturbing their rest.

Answer

The correct action is to withhold the medication and urgently notify the supervising registered nurse.
The correct answer requires the nurse to withhold the medication and notify the registered nurse. A respiratory rate of 9 breaths per minute indicates respiratory depression, a critical adverse effect of morphine. Administering the medication would worsen the condition. The practical nurse must ensure client safety by holding the offending agent and escalating the unstable assessment findings to the supervising RN for urgent medical intervention.

Step-by-Step Solution

1
Evaluate the older adult client's clinical presentation before proceeding with medication administration.
The client is difficult to arouse and exhibits a depressed respiratory rate of 9 breaths per minute (normal adult rate is 12-20 breaths per minute).
Identifying significant deviations from baseline vital signs is necessary to ensure it is safe to administer pharmacological therapies.
2
Analyze the assessment findings in relation to the prescribed medication.
Morphine is a potent opioid analgesic that carries a high risk for central nervous system and respiratory depression.
Connecting the client's symptoms to the known adverse effects of the prescribed drug dictates the immediate clinical response.
3
Determine the safest nursing intervention based on clinical prioritization and the practical nurse scope of practice.
The nurse must withhold the opioid dose to prevent further respiratory compromise and immediately escalate the situation to the registered nurse.
Airway and breathing are the highest priorities. An unstable client experiencing respiratory depression requires urgent RN-level assessment and potential medical interventions, such as administering an opioid antagonist.

Key Concept

Recognizing and managing opioid-induced respiratory depression within the practical nurse scope of practice.
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Topics

Pharmacological Therapies

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